Frozen Shoulder: Symptoms, Stages and Treatment

What is frozen shoulder?

Frozen shoulder, also called adhesive capsulitis, is a condition where the capsule of connective tissue around the shoulder joint becomes thickened and inflamed. Scar tissue forms, and the shoulder becomes painful, tight and stiff.¹

It is one of the most common causes of shoulder pain.¹

Frozen shoulder symptoms

• A deep ache in the shoulder that builds up gradually
• Pain at night, even when you are lying still
• Growing stiffness in every direction, most of all when turning the arm outwards
• Trouble with everyday movements such as reaching overhead, doing up a bra, or putting on a coat¹

What sets it apart from other shoulder problems is that the shoulder is stiff even when someone else tries to move it for you. Early on it can look like other painful shoulder conditions, so the diagnosis sometimes becomes clear only with time. Scans are not usually needed.¹ See shoulder pain.

The three stages

Frozen shoulder is traditionally described in three stages:¹

Real life is less tidy than the table. The stages overlap, and not everyone goes through all three.

Who gets frozen shoulder?

Most of the time there is no known cause. You are more likely to get it if you are:¹

• Aged 40 to 65
• Female
• Living with diabetes, a thyroid problem, or heart or neurological disease
• Recovering from surgery or an injury that kept the arm still

The link with diabetes is strong. A meta-analysis found that people with diabetes were five times as likely to have frozen shoulder, and that about 30 per cent of people with frozen shoulder had diabetes. The authors suggested that people with frozen shoulder be checked for it.²

How long does frozen shoulder last?

Symptoms often last between 18 months and three years.¹

The old teaching was that it always gets fully better on its own. The evidence doesn’t quite support that. A systematic review found that untreated shoulders improved but often not completely, and that most of the improvement came early, not late.³

In a study that followed 223 people for an average of 4.4 years, 59 per cent had a normal or near-normal shoulder. The other 41 per cent still had some symptoms, which were mild in almost all cases. Only 6 per cent had severe pain and loss of function. One in five developed it in the other shoulder, but it never came back in the same one.⁴

Frozen shoulder treatment

Early on: control the pain

• Change or avoid the movements that set off the pain, especially in the early months¹
• Heat, and simple pain relief as advised by your doctor or pharmacist¹
• An injection into the joint. A meta-analysis of 65 studies found this was the only treatment that was clearly better than the others for pain and function in the short term. Adding a simple home exercise program and physiotherapy may add to the benefit⁵
• Hydrodilatation. Fluid is injected into the joint to stretch the capsule. It may help most in the freezing stage¹

Physiotherapy and exercise

Physiotherapy is useful at every stage. A physiotherapist will show you how to move the joint and which stretches to do.¹ In the painful early phase, gentle movement within comfort is the aim. Forcing a very sore shoulder tends to flare it. Stretching becomes more useful as the pain settles.

On its own, physiotherapy is slower than an injection. A Cochrane review found that six weeks of manual therapy and exercise gave less improvement at seven weeks than an injection did.⁶

Surgery

Surgery may be offered if symptoms haven’t improved after 9 to 12 months. There are two main procedures. In a manipulation under anaesthetic, the surgeon stretches the shoulder while you are asleep. In a keyhole capsular release, the tight capsule is cut.¹

A large British trial compared both operations with a structured physiotherapy program that included an injection, in 503 people. At 12 months all three groups had improved a great deal, and the differences between them were too small to matter. Capsular release had more serious complications.⁷

What you can do

• Keep the arm moving within the range that is comfortable
• Do your exercises little and often
• Support the arm on a pillow at night
• If you have diabetes, keep up with your reviews
• Expect progress over months

When to see a doctor

• Shoulder pain and stiffness that are limiting your movement¹
• Night pain that is stopping you from sleeping
• Symptoms that aren’t improving, or are getting worse, despite treatment¹
• A shoulder that became stiff and painful after a fall or injury
• A shoulder that is hot, red or swollen, or you have a fever

References

1. healthdirect. Frozen shoulder.
2. Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J. 2016;6(1):26-34.
3. Wong CK, Levine WN, Deo K, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017;103(1):40-47.
4. Hand C, Clipsham K, Rees JL, et al. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231-6.
5. Challoumas D, Biddle M, McLean M, et al. Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581.
6. Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;2014(8):CD011275.
7. Rangan A, Brealey SD, Keding A, et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. Lancet. 2020;396(10256):977-989.